Primary care - mental health and wellbeing: outcomes and measures

The outcomes and measures framework provides an outline of outcomes, measures and indicators to demonstrate the system and people benefits associated with mental health in primary care provision.

Mental Health and Wellbeing in Primary Care – Outcomes and Measures Framework Guidance

The outcomes and measures framework was developed in 2022 to guide evaluation of the local implementation of Mental Health and Wellbeing in Primary Care Services. The guidance is available for areas with Mental Health in Primary Care workers and Community Link Workers in place and can be used for existing services and any future improvements. It is being published to allow local areas to use the guidance if they wish.

Mental Health and Wellbeing in Primary Care Services Indicators

Throughout the following indicators, the reference to the Service means any mental health and wellbeing provision provided in primary care. The following data collected by local areas, should be controlled by local information governance and data protection arrangements:

1. Personal data

  • Age range
  • Sexual orientation
  • Gender identity
  • Trans status
  • Postcode (Scottish Index of Multiple Deprivation (SIMD) 2020)
  • Disability
  • Ethnic group
  • Religion/belief
  • Does the individual have caring responsibilities

2. Individuals – Personal Outcomes

These indicators should be supported by capturing people's experience of the Service;

  • % of people who experience an improvement in wellbeing, following the provision of support coming into and exiting the Service. This should be measured using local tools, which should be identified when reporting.
  • % of people receiving treatment with improved clinical scoring clinical scoring, coming into and exiting the Service. This should be measured using local tools, which should be identified when reporting.
  • % of people receiving support and treatment who self-report an improvement in physical health. This should be measured using local tools, which should be identified when reporting.

3. Workforce

  • % of staff who are Trauma Informed Practice trained

4. Services & System Change

  • % of Services identified as trauma informed.
  • % of the population (mental health) presentations seen by GP without referral to the Service.
  • % of the population (mental health) presentations seen by GP, referred onto the Service.
  • % of the Health and Social Care Partnership population who accessed the Service.
  • (average) Time to being seen by the Service.
  • (average) Time to treatment intervention.
  • Average number of days/weeks people are supported by the Service.
  • Average number of contacts people have with the Service.
  • % of the population referrals from GP and Service to secondary Services.
  • (average) Time from first contact to referral onto secondary Service.
  • (average) Time to be seen by secondary Service.
  • % of people accessing the Service referred to wider community (not social prescribing).
  • % of people accessing the Service referred to social prescribing.
  • % of people accessing support out of hours offered support, assessment or treatment from the Service.
  • % of people, within the last 6 weeks, 3, 6, & 12 months returning to the Service who were previously discharged from the Service because of improved mental health and wellbeing.
  • % of people who are offered support and treatment 1-3 times, 4-6 times, 7 and more but did not take up any offer.

5. Digital

  • Number of referrals to digital self-managed resources
  • Number of referrals from Service to referred (supported) digital resources

6. Principles

  • All parts of the system should enable support and care that is person centred, looking to access the most appropriate information, intervention and support in partnership with the individual through shared decision making.
  • Trauma Informed Practice will be the norm. Wherever a person is in touch with the system they will be listened to and helped to reach the most appropriate place for them - there is no wrong door.
  • Primary Care mental health Services should have no age or condition/care group boundaries, and meet the needs of all equalities groups.
  • Local systems will positively seek to address health inequalities, proactively engaging those that are less likely to access support.
  • Digital approaches to self and supported management of distress and mental health conditions will be an integral part of the Service with the caveat that those who are digitally excluded need to be engaged positively in different ways.
  • Where support can be accessed to help an individual within the Primary Care setting in their own local area this should be the default. If referral to specialist Services is required, then this should be straightforward and timely.
  • People presenting in the Out of Hours period should have access to the full range of options available in hours, accepting some options may not be available immediately.
  • The Primary Care Mental Health Services (PCMHSs) linked to a group of practices or a locality to serve a population needs to be developed and resourced to provide appropriate levels of mental health assessment, treatment and support within that Primary Care setting.
  • Staffing levels within PCMHSs will be subject to, and compliant with, safe staffing legislation.
  • Evidence based psychological therapies need to be offered, with appropriate supervision and stepping up seamlessly to secondary care mental health Services where appropriate.
  • The use of screening and clinical measures pre and post intervention is encouraged, as this can indicate efficacy of intervention as well as assist with triage to ensure people are seen in the right Service as quickly as possible.



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